GRADE: C RECOMMENDATION
The AAFP recommends that clinicians selectively screen and refer adults age 18 years and older to OUD treatment after weighing the benefits and harms of screening and treatment. Clinicians should consider all benefits and harms including health, social, and legal outcomes. Screening programs should only be implemented if services for accurate diagnosis, effective treatment, and psychosocial supports can be offered or referred.
Clinical and Implementation Considerations:
The AAFP emphasizes the importance of early diagnosis, treatment, and referral of individuals with OUD. The AAFP recognizes that OUD is a complex health issue that has significant impacts of individuals, families, and communities. Family physicians play a key role in the diagnosis, treatment, and prevention of opioid use disorder. The AAFP strongly urges its members to be knowledgeable of and utilize evidence-based strategies to identify and treat OUD in the primary care setting, including medication assisted treatment (MAT).
The AAFP has reviewed the USPSTF’s recommendation on unhealthy drug use screening for adolescents and adults. Screening in this setting refers to asking questions about unhealthy drug use of asymptomatic persons. After careful review of the evidence reports commissioned by the USPSTF, the AAFP concludes that there is evidence to support a "C Recommendation" to screen for opioid use disorder in adults age 18 years and older.
The primary evidence report utilized by the USPSTF found that screening tools have acceptable sensitivity and specificity to identify drug use and substance use disorders in primary care.1 There are a variety of validated tools available and include self-administered or interviewer-administered tools that can be implemented in the primary care setting.
A second evidence report provided support in treatment seeking populations with opioid use disorders, that medication assisted therapies with opioid agonist therapy and naltrexone decreased risk of drug use relapse and increased likelihood of retention in treatment.2 The number needed to treated (NNT) to prevent one case of relapse with naltrexone therapy is 5.3 and with opioid agonist therapy is 2.9. The NNT for one additional case of treatment retention with naltrexone is 6.7 and with opioid agonist therapy is 2.6. Benefit of MAT in screen identified populations is uncertain. Evaluation of harms of pharmacotherapy is limited and inconsistent. No statistically significant improvements were observed in the screen-detected population. Specifically, brief interventions and psychosocial interventions aimed at reducing the use of illicit or non-prescription drugs in screen detected populations do not reduce drug use or improve health, social or legal outcomes.1 Therefore, the AAFP has weighed the benefit as small, which is indicative of a C recommendation.
When implementing this recommendation, readiness for treatment is a key in successful treatment of substance use disorders. When considering implementing a screening program for OUD, clinicians must consider potential harms such as stigmatization and medicolegal consequences of labeling. Clinicians must be careful not to participate in punitive screening programs, be aware of applicable state and federal laws, and implement strategies to reduce stigmatization of their patients.
This recommendation is specific for opioid use disorder in adults, including persons who are pregnant, but does not apply to adolescents. This recommendation is separate from AAFP’s statement on screening for other types of unhealthy drug use.
These guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These guidelines are only one element in the complex process of improving the health of America. To be effective, the guidelines must be implemented.